GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
Community Resilience and Public Health
Getting Actionable About Community Resilience: The Los Angeles
County Community Disaster Resilience Project
Anita Chandra, DrPH, Malcolm Williams, PhD, Alonzo Plough, PhD, MPH, Alix Stayton, BA, Kenneth B. Wells, MD, MPH, Mariana Horta, MPP,
and Jennifer Tang, MPH
Community resilience (CR)—
ability to withstand and recover
from a disaster—is a national pol-
icy expectation that challenges
health departments to merge di-
saster preparedness and com-
munity health promotion and to
build stronger partnerships with
organizations outside govern-
ment, yet guidance is limited.
A baseline survey documented
community resilience–building
barriers and facilitators for health
department and community-
based organization (CBO) staff.
Questions focused on CBO en-
gagement, government–CBO
partnerships, and community
education.
Most health department staff
and CBO members devoted
minimal time to community
disaster preparedness though
many serve populations that
would benefit. Respondents
observed limited CR activities
to activate in a disaster. The
findings highlighted opportuni-
ties for engaging communities
in disaster preparedness and
informed the development of
a community action plan and
toolkit. (Am J Public Health.
Published online ahead of
print May 16, 2013: e1–e9.
doi:10.2105/AJPH.2013.301270)
Published online ahead of print May 16, 2013 | American Journal of Public Health
Practice
THE NATIONAL POLICY
enthusiasm for re-envisioning the
preparedness agenda around
community resilience (the ability
to prevent, withstand, and mitigate
the stress of a disaster) raises
questions among local health de-
partments (LHDs) about how to
build or strengthen community
resilience and how to integrate the
“whole of community approach”
(a community-integrated model to
involve a diverse set of stake-
holders) in usual disaster-planning
activities.1---6 In the past 3 years, all
federal agencies that oversee and
fund state and local emergency
preparedness and response devel-
oped requirements and some
guidance to establish more of a fo-
cus on inclusion of communities in
emergency planning and response
activities, and as part of the Public
Health Emergency Preparedness
Cooperative Agreement, the Cen-
ters for Disease Control and
Prevention now requires a set
of capabilities in the area of
community preparedness and
resilience.2,4,7,8
The purpose of this focus is
2-fold. There is a recognition
based on previous disaster
experience domestically and in-
ternationally (e.g., Hurricane
Katrina, Joplin tornado, Hurricane
Sandy) that greater partnership
between government and a di-
verse set of nongovernmental or-
ganizations (NGOs; both for-profit
and nonprofit) is necessary for
more effective response and re-
covery.9---12 Furthermore, there is
new acknowledgment that the
principles of community engage-
ment used in other aspects of
public health promotion, including
those employed for daily stressors
(e.g., community violence), may
serve the best strategy for engag-
ing historically vulnerable popu-
lations, leveraging existing com-
munity assets, and integrating
routine and disaster activities.13
Moreover, the principles of com-
munity resilience (e.g., strengthen-
ing social connections, finding
dual benefit opportunities be-
tween routine public health and
disaster preparedness) address
many of the social and environ-
mental issues that aid communi-
ties to withstand and mitigate
overlapping disasters.12,14,15
This new approach requires
very different levels of partnership
Chandra et al. | Peer Reviewed | Government, Law, and Public Health Practice | e1
compared with the traditional top-
down disaster response approach
that has pervaded the past de-
cade.3,5,9,16---18 Yet, even though all
LHDs must address community
resilience capabilities as part of
their public health emergency
preparedness cooperative agree-
ment,7 key questions remain as to
how LHDs can operationalize and
measure this broader approach,
and there are few examples of how
to address these expectations. The
Los Angeles County Community
Disaster Resilience (LACCDR)
Project is a comprehensive,
community-based approach to an-
swer these questions through both
strategy and tactical activities,
moving community resilience from
conceptual (national policy and
associated literature on community
resilience) to operational (identify-
ing and testing resilience-building
activities in actual communities).
The structure of the partner-
ships, the Los Angeles County
Department of Public Health
(LACDPH) design strategy, and
the community engagement ap-
proaches used are described el-
sewhere in this issue.6,13 This
article summarizes findings from
 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

a baseline survey of governmental
public health and community
organizations to document initial
capacities and practices regard-
ing community resilience and de-
scribes the initial logic model for the
LACCDR project. The LACCDR
builds on a conceptual framework
for community resilience that em-
phasizes the engagement, education,
and interconnection of governmen-
tal and NGO partners considered
essential to a community’s ability to
mitigate vulnerabilities and recover
from stress.5,12,19
DEFINING COMMUNITY
RESILIENCE AND THE
CONCEPTUAL MODEL
The LACCDR effort was guided
by previous work in the area of
community resilience conducted
by several team members.5,20---22
This work included a literature
review on community resilience
in the context of public health
or national health security and
identified 5 core components of
resilience for health security: (1)
physical and psychological health
of the population, (2) social and
economic well-being of the com-
munity, (3) effective risk com-
munication, (4) integration and
involvement of organizations
(both government and nongov-
ernmental), and (5) social con-
nectedness (more details on data
abstraction are available5). This
security (any disaster with health
impacts):
The ongoing and developing ca-
pacity of the community to ac-
count for its vulnerabilities and
develop capabilities that aid in:
preventing, withstanding, and
mitigating the stress of an inci-
dent; recovering in a way that
restores the community to self-
sufficiency and at least the same
level of health and social func-
tioning as before the incident;
and using knowledge from the
response to strengthen the com-
munity’s ability to withstand the
next incident.23
Figure 1 outlines the levers and
core components of community
resilience based on this literature
review and stakeholder input.5
The core components are the
Levers of Community Resilience
Wellness - Promote pre-and postincident
population health, including behavioral health
Access - Ensure access to high-quality health,
behavioral health, and social services
Education - Ensure ongoing information to
the public about preparedness, risks, and
resources before, during, and after a
disaster
Engagement - Promote participatory
decision-making in planning, response,
and recovery activities
Self Sufficiency - Enable and support
individuals and communities to assume
responsibility for their preparedness
Partnership - Develop strong partnerships
within and between government and
nongovernmental organizations
main domains or factors associ- a population’s access to health
ated with community resilience, services.
such as the preexisting health of Wellness relates to pre- and
the population, derived from pre- postincident population health,
vious disaster research. It high- including behavioral health.
lights that community resilience Working to improve health is im-
depends on the strength of social portant because the overall resil-
connections among community ience of a community can rest on
members and between commu- the extent to which community
nity members and the community- members practice healthy life-
based organizations (CBOs) that styles. Promoting wellness also
serve their needs. It also depends involves taking steps to mitigate
on the underlying health and vulnerabilities either by planning
well-being of the community. The for or reducing (predisaster)
capacity of residents to respond a community’s vulnerabilities
and recover from a disaster re- (e.g., number of people who
quires that they have access to need transportation assistance)
timely information about the that, if ignored, can render emer-
threat and appropriate response gency response and recovery
mechanisms. The levers are the difficult.24---26
means of addressing these core Access relates to ensuring
components, such as by improving access to high-quality health,
Core Components of Community Resilience
Social and economic well-being of the
Community
community
Physical and psychological health of context
population
Effective risk
communication
information for all
populations
Social Ongoing
connectedness for Development
resource exchange,
of Community
cohesion, response, Resilience
and recovery
Integration and
involvement of
organizations
(govt/NGO) in
Ongoing disaster
planning, response,
and recovery experience

work also included a series of focus

groups nationally with government
and NGO stakeholders to solicit
additional perspectives on com-
munity resilience.5 This research
resulted in a definition in the
context of public health emergency
preparedness or national health
Ongoing Activities
Quality - Collect, analyze, and utilize data on building community resilience
Efficiency - Leverage resources for multiple use and maximum effectiveness
Source. govt/NGO = government and nongovernment organization. Data from Chandra et al.5
FIGURE 1—Core components and levers of community resilience, derived from disaster research.

e2 | Government, Law, and Public Health Practice | Peer Reviewed | Chandra et al. American Journal of Public Health | Published online ahead of print May 16, 2013

behavioral health, and social ser-
vices because these services con-
tribute to the development of the
social and economic well-being of
a community and the physical and
psychological health of the popu-
lation. Improving access ranges
from making appropriate links to
existing services to supplying new
services where none exist. Specific
to the disaster experience, educa-
tion (ensure ongoing information
to the public about preparedness,
risks, and resources before, dur-
ing, and after a disaster) can be
used to improve effective risk com-
munication. Community education
means that individuals know where
to turn for help both for themselves
and their neighbors, enabling the
entire community to be resilient in
the face of a disaster.
Engagement (promote partici-
patory decision-making in plan-
ning, response, and recovery ac-
tivities) and self-sufficiency
(enable and support individuals
and communities to assume
responsibility for their prepared-
ness)18,27---29 are needed to build
social connectedness particularly
in neighbor-to-neighbor reliance,
critical to resilience. Engagement
also includes the general level of
participation in preparedness and
resilience building, particularly for
at-risk or vulnerable populations,
which are often poorly integrated
into plans but face challenges in
recovery and response. Self-suffi-
ciency, or the active engagement
of individual citizens in response,
is important because individuals
are often the first responders to
incidents and must be effective in
bystander reactions. Furthermore,
we know that disaster conditions
can prevent the deployment of
Published online ahead of print May 16, 2013 | American Journal of Public Health
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
external aid until the acute phase of
the emergency has passed; thus,
communities have to leverage exist-
ing resources.30-- 33
Partnership (develop strong
partnerships within and between
government and NGOs) helps
ensure that government and
NGOs are integrated and in-
volved in resilience building
and disaster planning, another
essential feature of resilient
communities.9,18,34 Quality, or
a community’s ability to collect,
analyze, and utilize data, is a crit-
ical lever needed to monitor and
evaluate progress on building
community resilience.35 Finally,
developing sustainable processes
and resilience-strengthening ac-
tivities requires an integration of
any new efforts within the foun-
dation already established by
existing organizations. Greater
efficiency (leverage resources for
multiple use and maximum ef-
fectiveness) is particularly needed
in the processes involved in recov-
ery from a health incident because
significant human and financial
costs can be incurred as a result
of gaps in services or unnecessary
redundancies.16,20,36,37 As denoted
in Figure 1, both quality and effi-
ciency are reflected throughout the
entire resilience-building process.
The LACCDR program will
eventually focus on all 8 levers;
however, on the basis of discus-
sions in stakeholder working
groups on the most important
immediate needs, we are princi-
pally focused on bolstering the
3 levers of partnership, engage-
ment, and education at this stage.
We also focused on these 3 levers
because partnership and en-
gagement of the community
was cited as a critical goal
for LACDPH, and education is
essential to achieving broader
community participation and
enhancing resilience. Finally,
these levers are considered mu-
table by stronger networks
among government agencies
and NGOs. As such, they are
a means of achieving many of
the other levers, such as greater
community wellness or more
efficiency in linking routine
public health with disaster pre-
paredness activities (efficiency).
The objective of the baseline
survey was to measure the base-
line activities related to these 3
levers in the community resilience
framework, before the implemen-
tation of a 3-year capacity-build-
ing process, among the key
stakeholders of this project—the
LACDPH and members of the
Emergency Network of Los
Angeles (ENLA), an umbrella or-
ganization for CBOs, faith-based
organizations, and private-sector
organizations that serve in disaster
response support roles but pri-
marily provide routine services to
address community needs. This
network is the Los Angeles chap-
ter of Voluntary Organizations
Active in Disaster.
METHODS
The baseline survey was ad-
ministered via online platforms
(Survey Select and LimeSurvey),
preceded by an e-mail invitation
describing the study. Our survey
window was 3 weeks (between
February and March 2011), and
respondents were reminded 3
times via e-mail over that period to
complete the survey. The goal was
Chandra et al. | Peer Reviewed | Government, Law, and Public Health Practice | e3
to complete the baseline survey
before the first project kick-off
meeting, so that we captured atti-
tudes and activities before project
exposure.
Sample Characteristics
We surveyed a sample of staff
representing all divisions within
LACDPH and community organi-
zation members of ENLA during
February through March 2011,
before the first LACCDR commu-
nity meeting that marked the
official start of the LACCDR pro-
ject. We invited all ENLA member
organizations (n = 86) to partici-
pate in the survey and a stratified
sample of LACDPH employees
(by DPH division) via online in-
vitation (n = 190). We chose to
use a stratified approach to the
LACDPH survey because the
number of staff is quite large in
LACDPH (approximately n =
4000) and the stratification en-
sured that we received survey
representation from across the
divisions within the agency. This
was critical because 1 aim of
LACCDR is to bridge the disaster
preparedness work in public
health with other community
health activities (e.g., maternal and
child health). We selected staff
from each of 23 programs in
LACDPH. We randomly selected
names among levels of staff in
each program to ensure we in-
cluded program directors or man-
agers, service providers, and
administrative staff. We also
attempted to sample proportion-
ately to the size of the program;
thus, we had almost 40 to 50
names from each of the 3 largest
programs (Emergency Prepared-
ness and Response, Acute

Communicable Disease, and
Community Health Services).
Survey Content
The survey included 4 cate-
gories of questions—demographics
on the individual or organization
completing the survey including
roles in disaster preparedness, re-
sponse, and recovery (engage-
ment); strength of partnerships
between LACDPH and CBOs, and
among CBOs for disaster response
and recovery functions (partner-
ships); and current activities to
educate community members
about education and build resil-
ience (education). In addition,
we included questions about
TABLE 1—Question Content by Community Resilience Lever (Engagement, Partnership, Education)
Derived From Disaster Research
“Lever” or Domain Area
Engagement, including current level
of preparedness activity
Partnership
Education, including perspectives
on resilience
Note. ENLA = Emergency Network of Los Angeles; LACDPH = Los Angeles County Department of Public Health.
Source. Data from Chandra et al.5
e4 | Government, Law, and Public Health Practice | Peer Reviewed | Chandra et al.
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
barriers to strengthening commu- ability to withstand, mitigate, and capabilities (e.g., the ability of
nity resilience in Los Angeles recover from disaster. This en- community organizations to
County, and general resilience sured consistency with national educate their members about di-
perspectives. We also queried policy. Table 1 summarizes types saster or disaster preparedness;
LACDPH staff about whether of questions by lever. effective partnerships between
their division focused on 1 or We developed the survey items government authorities and CBOs
more of public health’s core ser- in concert with LACCDR steering including businesses and schools).
vices, and for ENLA, we queried committee members, representing The study team also reviewed
about a range of organizational LACDPH, ENLA, University of other disaster preparedness sur-
services and assets by using the California Los Angeles, and RAND veys to abstract relevant ques-
International Classification of leadership. In most cases, items tions that could be used or
Nonprofit Organizations and the were newly constructed for the modified for LACCDR; however,
role of nonprofits in disasters.38 study because of the limited sur- in most cases survey items
Because of the potential differ- vey questions in the area of com- did not exist for the concepts
ential definition of disaster, we munity resilience. However, we we planned to query in our
defined this term for respondents examined previous community instrument.39,40
to be a range of natural and resilience studies to identify We pilot tested the instrument
manmade disasters and defined response lists, such as core com- with 10 respondents (5 LACDPH,
community resilience as the munity resilience activities and 5 CBOs) to assess readability
and flow as well as to determine
if respondents interpreted the
questions as we intended.
Analyses were purposefully de-
scriptive at this stage because the
Question Content goal of the baseline survey was
Activities that organization conducts in disaster preparedness, to assess general community in-
response, and recovery (preparedness: risk communication, terest and challenges. In addition,
volunteer operations, training and exercises, animal services, partnership the sample size and differences
development, staff training, environmental preparedness, community in how LACDPH (individual staff
engagement; response: all and add staff mobilization; recovery: members nested in division within
all and add response and recovery evaluation) agency) and ENLA organizational
Engagement with “vulnerable” or at-risk populations, including modes representatives were sampled
and types of risk communication precluded robust comparison
General time allocation to disaster preparedness, response, and recovery with weights at this time. How-
Formal and informal relationship between LACDPH and various ever, we did disaggregate findings
community-based organizations (neighborhood associations, within LACDPH by representa-
faith-based organizations, businesses, other) tives of the Emergency Prepared-
Formal and informal relationships between LACDPH and ENLA ness and Response Program
Perception of individual or household and organizational readiness (EPRP) and all other divisions,
(preparedness education level) where relevant.
Proposed and future activities to disseminate information about disaster
preparedness and community resilience RESULTS
Perspectives on level of neighbor-to-neighbor reliance and volunteer capacity
Perspectives on community-resilience capabilities, including recent event We received 98 complete sur-
response (e.g., H1N1 influenza) and ability to educate community veys and 6 partial surveys from
LACDPH staff (out of 190,
response rate = 55%) and 29
surveys and 2 partial surveys
American Journal of Public Health | Published online ahead of print May 16, 2013

from ENLA (out of 86, response
rate = 36%).
We queried LACDPH and
ENLA respondents about their
division or department or organi-
zation type, respectively. Respon-
dents from LACDPH represented
23 programs within DPH. Ap-
proximately 30% (29 out of 98
surveys) of the LACDPH respon-
dents were from the EPRP. The
next largest groups were from the
Acute Communicable Disease
Program and Community Health
Services. For ENLA, most respon-
dents represented tax-exempt
charitable organizations, founda-
tions, or service organizations, and
most worked in social services,
followed by health or education.
Because ENLA represents
a wide range of organizations with
varying capacity, we queried re-
spondents about their overall paid
and volunteer staff size and their
membership, particularly as this
has implications for disaster resil-
ience. Twenty-one organizations
had individual members or con-
stituents, though reported mem-
bership size varied from 1 to
120 000 (the median membership
size was 40 and the mean mem-
bership size was 7383). Twenty
of the organizations reported hav-
ing between 1 and 15 000 volun-
teers (the median number of vol-
unteers was 200 and the mean
number of volunteers was 1278).
In addition to these basic de-
mographic characteristics, we
asked respondents to describe
their usual array of activities. The
LACDPH respondents were fo-
cused on a range of public health
core services, particularly moni-
toring health status, developing
public health policies, and
Published online ahead of print May 16, 2013 | American Journal of Public Health
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
engaging the community. Fifteen
of the ENLA organizations con-
sidered public safety or disaster
preparedness as a daily activity
(48%), followed by 11 organiza-
tions focused on human services
(35%), and 10 engaged in food
and nutrition activities (32%).
As this baseline survey also
served as a needs assessment to
inform the LACCDR project,
these data illustrated where
opportunities may exist to le-
verage community partnerships
in other parts of LACDPH or
with ENLA organizations (data
not shown).
Activities and Engagement in
Disaster Preparedness
We queried respondents about
their current activities in disaster
preparedness (on a scale of none
[0% time]; a little [1%---24%
time]; some [25%---49% time],
most [50%---74% time]; nearly all
[75%---99% time]; and all [100%
time]). Approximately 63% of
ENLA respondents noted that
they only spent “a little time” de-
voted to disaster preparedness
activities (< 25% time), which
could include disaster planning,
response, or recovery activities.
Representatives of divisions out-
side EPRP noted a slightly differ-
ent story, with 37% reporting
“a little” participation in disaster
preparedness and 31% reporting
at least some effort devoted to pre-
paredness (25%---49% time). Sixty-
nine percent of EPRP staff indi-
cated that they spent all or nearly
all of their time (75% or more) de-
voted to disaster planning activities.
In addition, we queried ENLA
organizations about their specific
activities in disaster preparedness,
response, and recovery activities
(Table 1). This information pro-
vided insight into their general
level of engagement, but also the
extent to which they were in-
volved in educating their staff and
community residents about pre-
paredness. Top responses for the
preparedness phase included or-
ganizational preparedness (50%)
and training and exercises (45%).
The ENLA organizations were less
involved in risk communication
(26%), partnership development
(35%), or environmental pre-
paredness (23%). In the re-
sponse phase, key ENLA activi-
ties were staff mobilization
(45%) and organizational re-
sponse (45%). Community en-
gagement was more commonly
cited in recovery (42%) rather
than preparedness (35%) and
response (29%).
As described earlier, engage-
ment addresses participatory
decision-making; therefore, a key
step is to ensure that vulnerable or
at-risk populations are included in
disaster preparedness activities.
The ENLA respondents tended to
report more engagement of these
populations than did LACDPH
staff. There were some distinctions
between ENLA, LACDPH---other
divisions, and LACDPH---EPRP
engagement of at-risk populations;
only 47% of EPRP staff noted
engagement of limited-English-
proficiency populations compared
with 56% of LACDPH---other di-
visions and 69% of ENLA re-
spondents. Approximately 57% of
EPRP staff noted engagement of
low-income populations compared
with 87% of LACDPH---other
divisions and 75% of ENLA
respondents.
Chandra et al. | Peer Reviewed | Government, Law, and Public Health Practice | e5
Current Partnerships in
Disaster Resilience
A critical aim of LACCDR is to
strengthen partnerships where
gaps exist, and to leverage current
partnerships particularly between
LACDPH and ENLA member
organizations where opportunities
exist to bolster community resil-
ience. Formal partnerships were
defined as having some type of
agreement in place including
a memorandum of understanding
or membership on a coalition,
where informal relationships were
defined as occasional meetings or
other correspondence.
We were most interested in the
types of organizations with which
LACDPH had partnerships (e.g.,
business, faith-based organiza-
tions) because these relationships
could be accessed and potentially
expanded through the ENLA
network in LACCDR. All other
divisions of LACDPH tended to
have fewer formal relationships
with neighborhood associations
(8%) and businesses (9%) than
with hospitals (34%) and health
clinics (34%). We found similar
trends for LACDPH---EPRP
though the business relationships
were more common (25% had
formal relationships). Only 39%
of ENLA organizations reported
a formal partnership with
LACDPH.
Education About and
Perspectives on Resilience
The third “lever” or arm of our
analysis was to assess education
activities provided by both ENLA
and LACDPH. In addition, we
were interested in exploring cur-
rent perspectives on resilience
(Figure 2). In general, relatively
 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

creating connections for social

There will be enough volunteers to
respond to and recover from
disaster
People in Los Angeles County can
rely on each other to help in a
disaster
Organizations in the area I serve
have knowledge to work together
to prepare for/respond to disaster
Individuals/families that I serve
have the knowledge to prepare for
and respond to disaster
0%
ENLA support, a key indicator of a
LACDPH community’s ability to rebound
from disaster.12
In terms of barriers to imple-
menting community resilience
activities, ENLA reported a lack
of materials in preparedness to
share with community members
(50%) and 25% noted a lack of
preparedness training. Staff of
LACDPH reported these barriers
to resilience—lack of community
interest in preparedness (40%)
compared with ENLA respon-
dents (25%), as well as lack of
organizational interest in pre-
20% 40% 60% 80% 100% paredness (25%) compared with
Agree or Somewhat Agree, % ENLA (18%).

Note. ENLA = Emergency Network of Los Angeles; LACDPH = Los Angeles Department of Public Health. DISCUSSION
FIGURE 2—Perspectives on current community resilience in Los Angeles County: survey of staff from Los The analysis of the early de-
Angeles Department of Public Health and Emergency Network of Los Angeles, 2011. velopment of the LACCDR pro-
vides an important and timely
template for practitioners devel-
few respondents agreed (or some- the public about H1N1 before it special needs or traditionally vul- oping similar resilience-building
what agreed) with statements that occurred (vs 60% of ENLA re- nerable populations compared strategies in response to new
individuals in their communities spondents), and nearly 80% felt with other areas of H1N1 federal mandates. Moreover,
had necessary preparedness satisfied in their ability to com- response. guidance from the Centers for
knowledge (28% ENLA, 20% municate information after the In addition to community resil- Disease Control and Prevention
LACDPH) and that people could event had started (vs 58% ience assessments, we asked re- on building more disaster-resilient
rely on each other in disaster (32% of ENLA respondents). The spondents about current efforts or communities is directed at all
ENLA, 30% LACDPH). However, LACDPH respondents were education to support community LHDs, but there are few examples
somewhat more respondents be- more satisfied with their ability resilience (Figure 3). The ENLA of challenges, particularly the ca-
lieved that there was organizational to improve individual or family organizations were more engaged in pacity of potential CBO partners.
readiness and knowledge to align preparedness before H1N1 than community resilience activities than By tracking and documenting
resources to improve community were ENLA respondents (65% LACDPH. About 36% of LACDPH these efforts in Los Angeles, all
resilience outcomes (39% ENLA, LACDPH were very or somewhat staff had educated constituents LHDs that must address these
37% LACDPH). satisfied vs 19% of ENLA organi- about preparedness, whereas 50% goals will have some early insight
Using H1N1 influenza as the zations). Approximately 42% of ENLA respondents had con- into ways to embark on similar
recent disaster example, we que- of ENLA organizations reported ducted that type of education. Ap- activities. Plus, this study provides
ried respondents about their sat- satisfaction with LACDPH ability proximately 55% of ENLA staff potential community resilience in-
isfaction that LACDPH currently to connect with CBOs in pre- reported educating constituents dicators for the field to analyze
exhibited core community resil- paredness compared with 55% of about preparedness and 75% as well as to provide a framework
ience capabilities, including edu- LACDPH staff. In addition, both reported disseminating information for measurement, which other
cating residents. Approximately LACDPH (42%) and ENLA (35%) (vs 38% and 45% of LACDPH staff, jurisdictions might use.
73% of LACDPH staff were satis- respondents were the least satis- respectively). The ENLA organiza- The baseline survey of
fied with their ability to educate fied in their ability to attend to tions reported more activities in LACDPH and ENLA

e6 | Government, Law, and Public Health Practice | Peer Reviewed | Chandra et al. American Journal of Public Health | Published online ahead of print May 16, 2013
 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

ENLA
Serves on a committee dedicated to preparedness
LACDPH

Assists partner NGOs in obtaining funding

Helps fill gaps in unmet needs

Refers community to educational/training services

Refers community to financial support services

Creates connections for community support

Educates community about preparedness

Disseminates info about emergencies

Ensures constituents know where to go in emergency

0 20 40 60 80 100
Participation in Each Activity, %
Note. ENLA = Emergency Network of Los Angeles; LACDPH = Los Angeles Department of Public Health.
FIGURE 3—Current community resilience activities implemented by LACDPH and ENLA: survey of staff from Los Angeles Department of Public
Health and Emergency Network of Los Angeles, 2011.

organizations provides an impor-
tant first snapshot for how these
staff members or organizations
view community resilience, their
baseline engagement in
resilience-building activities and
preparedness generally, and the
extent of current partnerships be-
tween LACDPH and CBOs. These
data provide the initial informa-
tion for assessing gaps in engage-
ment, partnership, and education
in both ENLA and LACDPH and
indicate the types of project activ-
ities that may be required to im-
prove resilience outcomes.
There are several findings of
note from this first survey. In the
area of engagement, many
LACDPH staff members, particu-
larly those outside of the EPRP,
did not devote significant time to
disaster preparedness activities
in the communities that they
served, yet they engaged many
of the vulnerable populations in
other public health promotion
activities that also require this type
of information. In addition, despite
the fact that current ENLA
members tend to be more
“disaster-ready” because of their
engagement within the Los
Angeles chapter of Voluntary
Organizations Active in Disaster,
many of these organizations still
only spend “a little” time in pre-
paredness. Furthermore, although
ENLA members focused time on
organizational readiness, they
noted less activity in partnership
development and community en-
gagement, which could be an asset
provided by ENLA organizations
in strengthening resilience. The
challenge for LACCDR is to build
institutional and community capa-
bilities in these areas before the
response phase.
In the area of partnership, the
survey responses are also infor-
mative. First, LACDPH and ENLA

Published online ahead of print May 16, 2013 | American Journal of Public Health Chandra et al. | Peer Reviewed | Government, Law, and Public Health Practice | e7

do not have many formal connec-
tions between these 2 organiza-
tions for disaster response and
recovery. Second, LACDPH also
has not fully leveraged community
partnerships that may be critical
for disaster resilience yet, princi-
pally those relationships with
nontraditional organizations that
have community reach, such as
neighborhood associations, faith-
based organizations, and busi-
nesses. In addition, the limited
participation of ENLA members
on preparedness committees (only
25% reporting membership)
could also change. For LACDPH,
there may be opportunities to work
with ENLA to engage constituents
in preparedness, particularly be-
cause LACDPH staff tended to re-
port less community interest in these
topics than did ENLA respondents.
Finally, perhaps the most criti-
cal findings were in the domain of
education, including activities to
disseminate preparedness infor-
mation and general perspectives
on community resilience. Al-
though community resilience rests
on the strength of individual and
neighborhood-level prepared-
ness,1,4,5,12,18 the assessment of
household preparedness and
neighbor-to-neighbor reliance in
a disaster was low. The majority of
LACDPH and ENLA respondents
did not think that individuals or
households in Los Angeles County
had the knowledge necessary to
prepare and respond effectively,
even though most of the ENLA
respondents noted that they spent
time educating their members
about disaster preparedness. As
ENLA organizations are already
developing social networks for
support as evidenced by their
e8 | Government, Law, and Public Health Practice | Peer Reviewed | Chandra et al.
GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE
current community resilience
activities (Figure 3), these organi-
zations may need to be leveraged
more consistently for broader
neighborhood and community-
preparedness education. Further-
more, although LACDPH was very
satisfied with its ability to educate
the public about H1N1 before
and during the event, most staff
members still identified a need
to improve both individual and
organizational preparedness.
Limitations
There are study limitations that
should be noted. First, the study
was conducted in a large county
and as such is most directly relevant
to other large metropolitan LHDs
(which do serve about 60% of the
US population). However, many of
the principles addressed in the
study (e.g., enhancing neighbor-
hood support, partnership between
government agencies and NGOs) are
critical to any community’s efforts to
strengthen public health and build
disaster resilience. Plus, the Los
Angeles County area contains urban,
rural, and suburban populations
representing diverse populations.
In addition, low survey return
rate from ENLA organizations is
a concern, though we obtained
a diversity of organizations in the
small sample including public
safety, health, education, human
services, and nutrition that com-
prise the majority of the ENLA
population. The low response rate
may be indicative of a lack of
engagement or lack of clarity
about the study’s purpose; both
issues should be addressed by
LACCDR. As such, we may be
obtaining perspectives from ENLA
members that are more engaged
in preparedness, perhaps under-
estimating some of the challenges
or barriers. Also, our survey was
focused on partnerships between
ENLA and LACDPH; we did not
query ENLA about relationships
with other government agencies.
In addition, as described earlier,
the sample design for this survey
purposefully allowed for descrip-
tive analyses only. We were un-
able to include subanalyses of
differences by ENLA organization
or LACDPH program type be-
cause of differential sampling
strategy and sample size within
groups. Future evaluation will in-
clude more robust measurement
of change over time in pilot neigh-
borhoods as well as comparison
between LACDPH divisions and
between LACDPH and ENLA.
Finally, the lack of tested measures
in community resilience is a limita-
tion. However, one objective of this
study was to further test and validate
items, such as those included in this
baseline survey, which could inform
a community-resilience index and
current national efforts to create
a health security preparedness index.
Conclusions
With the baseline findings and
a study logic model,41 the
LACCDR team has completed
a rigorous workgroup process,30
which guided the development of
the community resilience action
plan, principally through a com-
munity resilience toolkit. The
community resilience toolkit in-
cludes a set of strategies and ma-
terials that planning groups will
use over the next 3 years to build
resilience in their communities
including components that were
deemed high priority areas in
American Journal of Public Health | Published online ahead of print May 16, 2013
the survey such as partnership
development and social prepared-
ness. Findings from this survey
and the larger demonstration
evaluation13 will significantly ad-
vance the fields of public health
and disaster preparedness simul-
taneously, surfacing key strategies
that will build community resil-
ience, and assessing whether and
how indicators of partnership,
education, and engagement can
be improved to enhance that
resilience. This baseline assess-
ment represents an important first
step toward understanding com-
munity resilience challenges and
opportunities in a large county
and illustrates specifically how
government and NGOs can
strengthen ties and leverage
a greater diversity of assets to
more effectively respond to disas-
ters or other emergencies. j
About the Authors
Anita Chandra is with RAND Corporation,
Arlington, VA. Malcolm Williams is with
RAND Corporation, Santa Monica, CA.
Alonzo Plough is with Los Angeles County
Department of Public Health, Los Angeles,
CA. Alix Stayton is with Emergency Net-
work of Los Angeles, Los Angeles. Kenneth
B. Wells and Jennifer Tang are with the
Center for Health Services and Society,
University of California, Los Angeles.
Mariana Horta is with Princeton Univer-
sity, Princeton, NJ.
Correspondence should be sent to Anita
Chandra, DrPH, RAND Corporation,
1200 South Hayes St, Arlington, VA
22202-5050 (e-mail: chandra@rand.
org). Reprints can be ordered at
http://www.ajph.org by clicking the
“Reprints” link.
This article was accepted February 3,
2013.
Contributors
A. Chandra led the oversight, design, and
conduct of the study. M. Williams con-
tributed to survey design, data analysis,
and article development. A. Plough ad-
vised on survey design and content as

well as article revisions. A. Stayton and K.
Wells contributed to survey content, and
A. Stayton facilitated survey administra-
tion. M. Horta led data analysis. J. Tang
contributed to survey administration and
data analysis.
Acknowledgments
This work was supported by Centers for
Disease Control and Prevention (grant
2U90TP917012-11).
The authors wish to thank survey
participants and Brittney Weissman and
Benjamin Bristow for their commitment
to the project.
Note. The findings are those of the
authors and do not necessarily represent
the views of the funders.
Human Participant Protection
The study was reviewed by the RAND
Human Subjects Protection Committee
and deemed exempt.
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